Tuesday, February 12, 2013

Orthorexia Part Three: Risks of Different Diets

This weekend I was away in Utah at the inaugural Physicians and Ancestral Health conference. More on that later, but I'm linking now to Victoria's take. It was a terrific weekend, and I do want to take some time right now to thank Rick Henriksen, John Barret, and Lucy Flynn for organizing the conference. In addition I would like to thank Jacob Egbert for hosting me and inviting me to check out his incredible gym. We also got to work out at Ute Crossfit and meet some of the athletes who won the 2012 Crossfit Games. In the midst of all that, I wasn't able to keep up with posting all the comments coming in. All of them should be up at this point.

Back to Orthorexia, a popular term coined by Steven Bratman, MD to describe those pathologically preoccupied with food and diet. His book, Health Food Junkies, is quite an interesting read, and a bit of an indictment of some of the alternative medicine scene (Bratman was an alternative practitioner before becoming an MD, and continued to practice many alternative therapies thereafter).

Anyway, a question arose in the comments of the first post about those of us who follow a paleo or primal-style diet. Is there something about the diet that could lead to Orthorexia? To answer that question, I'll go through some of Bratman's experiences with people in different diets that he thought were especially prone to go over the edge from careful, healthy eating into dietary obsession that interfered with daily life and functioning.

1) Food allergy diets: Bratman found that many people benefited from wheat and dairy removal for all sorts of ailments. But he tells of a number of different sorts of woo-woo sounding tests (bioelectric impedance, energy fields and muscle resistance while holding a vial of a food, and of course the infamous IgG tests*). Anyway, regardless of the method, people would invariably get a list of several foods they had a major intolerance to (almost always including dairy and wheat), and then a longer list of "minor intolerances" of random foods from tomatoes to onions to lamb or parsley or…you get the idea. So the person will get rid of the "major" intolerances and tend to feel a lot better. But there might be some residual lack of energy, or cramping stomach, or mental fog…so they eliminate all the minor foods. In general it is difficult to completely abstain from the off limits food, and people tend to binge or "cheat" and feel guilty, followed by renewed, stricter dieting. Every physical and mental symptoms gets correlated with some sort of food, and diets can get very limited, and life can revolve entirely around food. Ultimately, maybe the person would be happier with residual symptoms and a more varied palate.

I see the food intolerance route as the major avenue into Paleo/Primal Orthorexia. I feel great and my cellulite went away eating paleo…let's try an autoimmune protocol so those funny little red spots on my shoulder will go away…hmm, maybe the histamine in this food is making my nose run, or maybe the FODMAPS are causing that funny cramping I get sometimes…I'm just going to eat pemmican and see how that goes. Now sometimes these dietary trials are fun, interesting, and can lead to positive health changes. Sometimes they are annoying or even debilitating obsessions.

2) Macrobiotics: I had heard of this diet before, but never knew that much about it. The diet is based on Taoist principles and involves vegan foods balancing yin and yang. Mostly that seems to mean eating brown rice, little julienned and lightly sauteed vegetables, and spending a lot of time agonizing over the balance and beauty of the meal. You are also supposed to restrict water to some extent. This diet is perfect for people who get a thrill out of obsessing over food. Bratman practiced macrobiotics for a while, and claimed there is a particular look to people who ate that way:

The skin looks slightly darker than usual; it's tight, without any hanging folds or obvious smile lines. The shape of the face itself seems different, too, perhaps again due to the tightness of the skin. It's more angular, more like a polygon than a circle or an oval.

Like many vegan diets, it can lead to a feeling of lightness that is pursued by the practitioners. Macrobiotics preaches asceticism. Bratman tells a horrible tale of having to call child protective services on one macrobiotic couple who water-restricted their child as part of the diet.

3) Raw Food, Fruitarianism: Bratman felt that the raw foodists and fruitarians were among the most likely to fall into the deadly form of orthorexia, leading to undereating and starvation, or, as one of his patients who only ate raw vegetables did, passing out while driving and dying in an accident. These diets tend to lead to a feeling of airiness and lightness, a pursuit of separation and denial of the physical self. In some ways, the paleo-style diet, being meaty and hedonistic and filling (and more nutritionally complete than any vegan diet, though endurance exercise raw vegans can consume enough calories to get more mirconutrients than you would think) may be the opposite and reasonably unlikely to lead to deadly orthorexia. However, intermittent fasting can also lead to that light and airy feeling, and one could take that too far.

4) Zone diet: The obsessing over macronutrient ratios, Bratman thought, could lead one into food obsessiveness in general. "Orthorexic Zoners spend much of their day talking about their diet and debating the fine points of their theory like Talmudic scholars using the works of Barry Spears as scripture." (Just replace some names here and you get the paleo/primal-style equivalent). Bratman does mention the "caveman diet" in his book under "zone" as a "stricter version" of the zone involving eating wild plants (he mentions "weeds ripped out of a nearby wetland and scarfed raw like salad along with fresh deer" What? He got his information from NeanderThin, which may be as weird a book as I would hope. Any of you read it?). Health Food Junkies was published in 2000. He might have had a field day with his paleo-style diet chapter today…wonder if he's ever been to Paleohacks?

5) "Pill Orthorexia" Bratman has a chapter for the supplement fanatics who come in with their bags of pills, looking for the perfect regimen, alternating between different chelates of magnesium and separating the calcium from the zinc and balancing the A, B, C and D…sound familiar?

All in all, finding the perfect diet reminds me of sanding and painting a wall. One can sand and sand with finer and finer grit, and paint layer after layer and obsess over imperfections for many days and weeks. But ultimately, one gets 90% of the way there, and the extra benefit becomes an asymptote that once can chase forever with increasing percentages of "perfection."

My father gave me some good advice when I was going off to college. He told me to try to get the lowest A in the class. That way I would have spent my time efficiently and collect those 4.0s while having hobbies and a life without making myself nuts trying to achieve the highest possible grades all the time. For the most part, for most people, I think diet is the same way.

*I remember in one of Chris Kresser's podcasts he said he sent off blood for two of these tests at the same time (they are expensive, maybe he got a bargain price ;-), and got back completely different results.

29 comments:

"The skin looks slightly darker than usual; it's tight, without any hanging folds or obvious smile lines. The shape of the face itself seems different, too, perhaps again due to the tightness of the skin. It's more angular, more like a polygon than a circle or an oval."

I think it's stuff like this that makes people skeptical of Bratman and his Orthorexia concept. Probably most people he describes could be diagnosed with more well-studied and described disorders like "generalized anxiety disorder."

Yes, you won't see it in the DSMV any time soon. The main advantage of the word as opposed to "food-related anxiety" is that most people know what you are talking about when you say it. But in many cases it would fit under OCD or types of food phobias, or more generalized anxiety.

Because there are better-documented and scientifically validated therapies for things like anxiety disorders and OCD. Orthorexia is an interesting concept, but I don't see Bratman making an effort to refine it into a useful diagnostic entity.

I've read NeanderThin - I came across it during an evolutionary psychology course and used it as the basis of a project and followed the diet myself for a week or so without any difficult (or resulting orthorexia ;-) ) It's actually not bad, pretty hard to argue with most of it, and I don't know how Bratman interpreted it as being all about weeds and wild deer. It holds up pretty well to current thinking on an appropriate paleo diet, and doesn't seem any more likely to lead to orthorexia than, say, "It Starts With Food". But it had a bad title and no marketing and predated the rise of paleo diets enough that it didn't sell well.

Emily, could you be more specific? Are you talking about being too picky? Or are you describing an actual medical condition? Your post is about orthorexia -- what would you need to see in a patient to commit to this as a diagnosis? Because lots of "paleo" people are trying to sell "orthorexia" as an actual mental problem.

And no doubt you're more discerning than most, but there are probably more than a few MDs who wouldn't even recognize celiac when it's in front of them, and would pooh-pooh that patient's complaints about wheat.

...finding the perfect diet reminds me of sanding and painting a wall. One can sand and sand with finer and finer grit, and paint layer after layer and obsess over imperfections for many days and weeks. But ultimately, one gets 90% of the way there, and the extra benefit becomes an asymptote that once can chase forever with increasing percentages of "perfection."

Well, that's why it would be helpful to know what you mean by these terms. What do you mean by "perfect diet"? And who is "one" -- an already-lean 20-something in search of a six-pack, or 60-year old striving to maintain a 200 lb. loss? What is 90%? 90% of the carbs compared to the SAD? Or 90% of the wheat? Are celiacs orthorexic if they strive to remove more than 90% of the wheat the average American eats? And what is the "extra benefit" you're talking about?

I have a friend who is so allergic to fresh parsely that she is literally off the charts; her reaction is so extreme that it can't even be quantified. She's allergic to the point that a piece of parsely too small to be recognizable as parsely could kill her.

Obviously my friend is not orthorexic when she carries two epi-pens everywhere and still interrogates waiters, but anyone overhearing her would think she's crazy.

My father gave me some good advice when I was going off to college. He told me to try to get the lowest A in the class. That way I would have spent my time efficiently and collect those 4.0s while having hobbies and a life without making myself nuts trying to achieve the highest possible grades all the time. For the most part, for most people, I think diet is the same way.

But an A- never killed anyone. For some people, being casual with diet will kill them. For others, it will advance their diabetes and obesity.

It's one thing to have those people critiqued by MDs like yourself. But I hate to see those people being marginalized by being diagnosed by various marketers with no medical training.

"For some people, being casual with diet will kill them. For others, it will advance their diabetes and obesity."

Seems to me after several years of reading all these blogs and the comments that these people are keenly focused on everything they eat but not at all focused on moving. I think that going extended periods of time without moving will also advance diabetes and obesity.

She's clearly not talking about people with *real* food allergies. But when people who have "food allergies" that have been diagnosed by methods that have not been scientifically validated and who don't have any observable reaction to those specific foods go to great lengths to avoid an enormous list of foods, there's a problem, and that problem is not food allergies.

It is not so simple with allergies. Some foods like strawberries, citrus fruits,and more, also alcohol make people more prone to have severe allergic reaction on proven allergen. For example with me having a cat allergy, it is a bad idea to consume alcohol when I visit my friend who has cats in her household.

Indeed. If I eat cheese I can usually handle the slight reaction, well worth it for the nutrition, but if I eat cheese on a high pollen count day, I am very likely to have rhinitis and start sneezing later. Without dairy, this wouldn't happen.

I have been obsessed with the perfect 'philosophy' for eating food in relation to body image (including where the positive role of diet ends and the negative effects of self restraint begins). By obsessed, I am probably talking about the OCD type of obsessed - short circuiting thoughts, intrusive, inability to enjoy a tv show or a nice night of sleep with out sentences and ideas repeating on themselves. Torture, really. Obsession isn't simply a passion you spend all your free time doing. Food has been a convenient matter to obsess about because I have a problem with food - if one can be technically addicted to food, I think I would be that. Yet, adopting a few key ideas from paleo principles I am starting to deal with my obsessive nature (paleo is not a cure, it is a platform). It is freaking hard to draw the line though, adopting a new diet to help your obsession when obsession with eating is what you are trying to break away from. From my perspective, orthorexia exists, but more likely a form of OCD? And it can't be applied to everybody overly optimistic about effects of a certain diet. It is a messy messy business. Hats off to you Emily Deans for making your career in a very grey area of psychiatry.

I think there is a danger in learning about different diets through the eyes of someone who is seeing just the weird cases. That would be like saying that all religious people are bad because there are a few in every group who can take things to extremes, like beating up kids or locking their wives up in the compound. If you are going to go after macrobiotics, you should be prepared to also go after 7th day Adventists or orthodox Jews. They are all philosophy-based ways. We would never imply that keeping a kosher kitchen is akin to an eating disorder because they follow rules with care that seem strange to others.The traditional macrobiotic diet is more like an Asian Weston Price, more on the vegetarian side, but it is not necessarily vegan. In fact, for most people, fish is recommended at least once a week. I would agree that when taken to extremes, it does get to be a bit like paleo, but certainly not as black and white as some paleo plans making the rounds these days. No food is entirely banned, things are just more or less balanced. Eating more and more rice the worse off you are healthwise is similar to the common paleo recommendation to add even more potatoes, or to IF just a little bit longer for just about every health condition.Yes, the water thing was weird. I never restricted it, but then again, I never followed that 8-glasses-a-day rule that is so prominently featured in SAD calorie-reduction diets. I never got sick from not drinking water on a macrobiotic plan, but I am old enough to remember getting in trouble in gym class for sneaking over to a drinking fountain for a gob of water. The coach didn't want us to drink all that nasty water and get sick all over the basketball court. My how times change.

I haven't read Ray Audette's Neanderthin, but we have to consider him a modern paleo pioneer. For anyone interested, the Dallas Observer has on online profile of him: http://www.dallasobserver.com/1995-07-06/news/neander-guy/I think he's still in Texas and likes bluegrass music. He hunts or hunted some of his food with a hawk!

Here's particularly florid version of the Zone Diet turning someone into an obsessive, with interesting results. Another example of astrophysicists looking inward - I think this guy really needs to talk to Paul though.

Where I think he gets it utterly right is, that health in the future will require computer programmers as well as doctors. You can't read the genome off the page and apply it, deciphering the interactions between genes, diet, drugs and so on will consume armies of computer geeks.

Imagine The Social Network, armies of kids drinking soda eating snacks and staying up all night as they write codes that will ultimately aid some doctor to help a particular patient to eat the right kind of nutritious food and get a good nights sleep.

"I then remembered Neanderthin, a book that came out while Protein Power was going through the publication process. It originally was a little, self-published paperback I happened upon in a Borders (RIP) in Dallas. And it probably would have escaped my notice had I not been so attuned to dietary anthropology. I tracked down the main author, Ray Audette, who lived in Dallas. MD and I had dinner with him and his wife a time or two, and after his little paperback had sold enough copies, he got a mainstream contract, and I agreed to write the forward to his mainstream-published book."

I'm guessing if Dr. Eades wrote the intro it's probably not completely nutty. (I've not read it either, but I'd like to.)

"Now sometimes these dietary trials are fun, interesting, and can lead to positive health changes. Sometimes they are annoying or even debilitating obsessions."

ah, it depends on who is doing the diagnosis, doesn't it? Some of my friends and relations probably ARE "annoyed" by my preferring to avoid foods that react on me badly -- but who are they to judge? The ones i'm thinking of would FAR prefer to not know that the CIAB they love is making them sick. They want to eat their poptarts and still believe they're a "healthy part of this complete breakfast".... I may "annoy" them by insisting on real food, but that's just tough shit.

I guess the ortorexia discussion hit such a nerve because many people perceived it is another possible ground to misjudge and dismiss their individual food restrictions. My husband(who is 52) still remembers how he was forced to drink cocoa in a daycare by the staff while he didn't tolerate it well due to allergies. They persisted until he vomited, only then he was left alone. People with allergies, gluten intolerance, IBS, thous who restrict carbohydrates without being Diabetics , are often criticized for being too "picky", and often are told "it is all in your head", while Diabetics, people with religion-based restrictions,with a deadly form of peanut allergy, and for unknown reason vegetarians (you can request a vegetarian meal in an airplane, for example), are accepted by general public as normally behaving individuals.

Well, Galina, there are a LOT of vegetarians, and if you call them crazy you've instantly made a ton of career-long enemies. That's a problem for would-be gurus who have yet to quit their marketing jobs. Can't risk a PR nightmare for the real boss!

But it's also not hip to be intolerant of vegetarians, because before their health fails they tend to be young women. What blogger doesn't want to be admired by 20-something women? Heck, many diet bloggers ARE 20-something women!

Low-carbers make much better targets. They're typically fifty and sixty-somethings who just don't want their obesity to return. Not as web-savvy. No longer 'hotties.' UNCOOL.

They're soft targets. It's like beating up on your mom.

For all the nonsense about the "Low Carb Hezbollah", low carbers are a shrinking group that's largely being bashed by former low-carb gurus (an astonishing number of whom are current or ex-personal trainers) trying to establish their paleo "bona fides" as they desert the sinking low-carb ship.

@Unknown,From the business perspective vegetarians are very good for generating sales profit. LCarbers are possibly the worst especially if they don't buy LC versions of carb junk. BTW, on the graph from the link you provided, the interest to LCarbing is stable, not shrinking , but Paleo is getting into the trendy category and is on the rise. I guess, it is the logical escape route for both vegetarians who suffer from the lack of nutrients found either in animal food or supplements, and LCarbers who don't really need a strict restriction of carbohydrates. It could be also the effect from a very successful marketing by Dr.Davis his "Wheat Belly" book. To tell you the truth, I belong to the uncool category.

LC leveled off a long time ago, but it was the Big Kahuna that people like Robb Wolf and others were chasing when they got into the game. But yes, it's clear that Paleo branding is where the smart money is now.

Where the Google Trends data gets especially interesting is when you click on the tabs to break out where the 'paleo' searches are coming from vis a vis 'low carb.'

The low carb searches are coming from DiabetesLand -- the deep South, the Midwest, and Appalachia. The "paleo" searches are coming from HipsterLand -- Seattle! Portland! Boulder! Austin!

IMHO, one group needs help rather than derision (and especially not accusations of insanity.) And the other group needs to be au courant.

Also interesting is the annual peak in interest, for all diets, around December - people researching for New Year's resolutions?

In any case, I'd say even Paleo is nearing or at its peak, or at least, hard core, low carb (no rice, spuds), no dairy paleo - the Paul Jaminet style "safe starches"/ Perfect Health Diet is where it's at now...

Interestingly, the biggest spike came from an article in Canada's National Post which defines orthorexia this way:

In this day and age, we are also seeing an increase in what some call “orthorexia,” a condition where an individual becomes obsessively fixated with high-quality food

...which amuses me a little as some of the bloggers accusing others of 'orthorexia' are foodies who blog about the gastropubs they haunt, the arcane ingredients in their food and seemingly never eat without subjecting the poor dish to an intensive photo shoot. Actual photo captions:

Maybe people are googling "vegan" to try to understand the cause of their friends' insanity and physical decay.

There's a reason why vegetarians are treated as if they were normal. Because they are seen as trying to do a noble thing by denying themselves the demons of meat and animal fat. it's a puritanical thing, whereas low-carbers are seen as self-indulgent.For perhaps good reason, the person avoiding meat and animal fat is seen as making a bigger sacrifice (as if for the common good, or for holiness) than the person avoiding carbs. There's no odour of sanctity about eating Atkins.

@Unknown,I agree with you that paleo more fit the "cool" category. My impression - it is slowly becoming the standard diet for the snobbish crowd and well payed people. Better than vegetarianism, for sure. Probably, people who continue to follow a LC trend have different priorities than fitting into the current diet trend and more practical reasons to stick to their diet. If you take me as an example, I think that it is absolutely not cool to have migraines, hot flashes and regain weight, and I hold it to a higher priority than fitting into the modern crowd. Robert Wolf is absolutely right from the business perspective that he abandoned people like me - we both don't need each other. I wouldn't notice without you telling me .I see the current process is a natural one. Trends are the subject to change. I think that in a reality perfectly healthy people who feel that it is important to eat according to a latest trend (or in order to reach an absolutely perfect state of health, together with the most spectacular middle-section definition) behave more like ortorexics than any IBS sufferer, allergic, LCarber who can't tolerate the PHD levels of carbs consumption. However, it is ironic that it is the first group that often ridicule the second one.

I read NeanderThin (found it in a used bookstore when first starting paleo two years ago) and still go back to it when I want to read something with no BS to remind me how simple it can all be. I don't treat it as a bible, but I value its voice.

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About Me

Emily Deans, M.D.: I'm a psychiatrist in Massachusetts searching for evolutionary solutions to the general and mental health problems of the 21st century. Disclaimer: This information is for educational purposes only, and is in no way intended to be personal medical advice. Please ask your physician about any health guidelines seen in this blog, as everyone is different in his or her medical needs.